eating disorders 101: signs, symptoms, screening, and referral€¦ · anorexia nervosa (an)...

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Eating Disorders 101: Signs, Symptoms, Screening, and Referral

Anna Bardone-Cone, PhDBowman & Gordon Gray Distinguished Term Professor of Psychology, University of North Carolina at Chapel Hill;Director of Clinical Psychology

Louise Metz, MDInternal Medicine PhysicianMosaic Comprehensive CareChapel Hill, NC

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What is NCEED? • National Center of Excellence for Eating

Disorders (NCEED)• Established thanks to a SAMHSA grant from

the U.S. Dept. of Health and Human Services • Primary mission: education and training

– Healthcare professionals– Public stakeholders

• Web-based platform in development—sign up to stay informed!

www.nceedus.org

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www.nceedus.org3

Goals• Describe DSM-5 eating disorder (ED) diagnoses

• Identify evidence-based screening measures for

eating disorders

• Review evidence-based practices for an initial

medical work-up following a positive screen

• Recommend ways to approach patients you have

concerns about & provide referrals

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eating disorders





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Anorexia Nervosa (AN)Diagnostic criteria:

- restricted dietary intake leading to significantly low weight for age, height, sex, & developmental trajectory

- intense fear of gaining weight or becoming fat (or behavior interfering with weight gain) despite low weight

- disturbed body perception OR self-evaluation overly due to weight/shape OR persistent lack of recognition of seriousness of low weight

Subtypes: Restricting; Binge-eating/Purging

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Bulimia Nervosa (BN)Diagnostic criteria:

- recurrent episodes of objective binge eating & inappropriate compensatory behaviors intended to prevent weight gain

- on average, at least 1x/wk for 3 months

- self-evaluation overly due to weight/shape

- does not occur solely in the context of AN

https://www.youtube.com/watch?v=STkBb9mo0fQ

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Objective Binge Eating, Compensatory Behaviors

Binge = sense of lack of control over eating during the episode

= unusually large amount of food

= discrete period of time (e.g., within 2 hours)

Compensatory behaviors

Ex, self-induced vomiting, laxatives, diuretics, fasting, excessive exercise

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Binge-Eating Disorder (BED)

- recurrent episodes of objective binge eating

- on average, at least 1x/wk for 3 months

- absence of regular inappropriate compensatory behaviors

- 3+ of the following: eating more rapidly than normal; eating until uncomfortably full; eating large amounts when not hungry; eating alone because embarrassed; feeling disgusted with self, depressed, guilty after binge

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Anorexia Nervosa Bulimia Nervosa Binge Eating Disorder

Lifetime prevalence(for females)

< 1% ~2% ~3-4%

Age of onset early-to-late adolescence

mid-adolescence to young adulthood

adolescence or young adulthood

Gender more females more females more females, fairly balanced

Comorbidity anxiety, depression, trauma (for binge/ purge subtype)

anxiety, depression, substance use disorders, trauma

anxiety, depression, substance use disorders, trauma

Race, ethnicity all races and ethnicities

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Avoidant/Restrictive Food Intake Disorder (ARFID)Diagnostic criteria:

- eating/feeding disturbance(e.g., lack of interest in food; food avoidance due to sensory characteristics) associated with 1+ of the following:- significant weight loss or failure to achieve expected weight gain (for

children)

- significant nutritional deficiency

- dependence on enteral feeding or oral nutritional supplements

- marked interference in psychosocial functioning

- unlike AN, no significant distress about weight/shape

- not explained by lack of available food or a culturally sanctioned practice

- Note: ARFID most commonly develops in infancy/childhood & can persist into adulthood

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Other Specified Feeding or Eating Disorder (OSFED)

Examples:• Atypical anorexia nervosa – all criteria but, despite

significant weight loss, not underweight

• Bulimia nervosa or binge eating disorder of low frequency (e.g., < 1x/wk) or limited duration (e.g., < 3 months)

• Purging disorder – recurrent purging behavior to influence weight/shape in the absence of binge eating

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Warning Signs and Symptoms • Preoccupation with food, eating, calories

– Often cooking/baking, but refusing to eat

– Watching cooking shows

– Counts calories obsessively

• Reluctance to eat with others– Frequently saying, “I’ve already eaten.”

– Bringing own food to meal outings

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Warning Signs and Symptoms • Food rituals

– Cutting food into small pieces

– Pushing food around the plate

– Excessive use of condiments

• Secretive behavior related to eating– Food missing

– Wrappers in car, bedroom

– Regularly using the bathroom shortly after eating (to vomit)

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Warning Signs and Symptoms

• Weight and shape concerns– Frequent self-weighing

– Wearing baggy clothes to hide shape

– Scrutinizing shape in mirror

– Body checking

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What Do EDs “Look Like”?• What: Eating pathology is a spectrum

• Who: Eating disorder stereotypes are misleading

• Eating disorders affect:

– males

– racial/ethnic minorities

– individuals with low SES – e.g., living with food insecurity

– sexual and gender minorities

“Marginalized Voices” from NEDA: https://youtu.be/OU768PVZvgY

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Biopsychosocial Model of Eating Disorders

BiologyDietingGeneticsPhysical changesPuberty/MenopauseBrain Chemicals

PsychologyStressful eventsCoping skillsIdentify/self‐imagePersonality (e.g., perfectionism, impulsivity)AnxietyDepression

Social/environmentCultural factorsPressure from: family, peer, mediaMedia/social media messages about appearance

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Early Detection is Key! • Patients rarely present directly for eating

disorders care

• Patients may be secretive or ashamed

• Routine screening with PCP or mental health provider– Leveraging existing relationship

– Avoiding judgment

• Early diagnosis and treatment = better prognosis

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Screening for Eating Disorders

• SCOFF

• Eating Disorder Screen for Primary Care (EDS-

PC)

• Screen for Disordered Eating (SDE)

• NEDA Screener

(https://www.nationaleatingdisorders.org/screening-tool)

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SCOFF Questionnaire• Do you make yourself Sick (vomit) because you feel

uncomfortably full?• Do you worry you have lost Control over how much you

eat?• Have you recently lost more than One stone (14 lbs) in a

3 month period?• Do you believe yourself to be Fat when others say you

are too thin?• Would you say that Food dominates your life?

2 + “Yes” responses = positive screen (sens 86%, spec 83%)

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Eating Disorder Screen for Primary Care

• Are you satisfied with your eating patterns? (“reverse-scored”)

• Do you ever eat in secret?

• Does your weight affect the way you feel about yourself?

• Have any members of your family suffered with an eating disorder?

• Do you currently suffer with or have you ever suffered in the past with an eating disorder?

2+ “yes” responses = positive screen (sens 97%, spec 40%)

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Screen for Disordered Eating • Do you often feel the desire to eat when you are

emotionally upset or stressed?

• Do you often feel that you can’t control what or how much you eat?

• Do you sometimes make yourself throw up (vomit) to control your weight?

• Are you often preoccupied with a desire to be thinner?

• Do you believe yourself to be fat when others say you are thin?

2+ “yes” responses = positive screen (sens 91%, spec 56%)

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NEDA Online Screen

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www.nationaleatingdisorders.org/screening-tool

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NEDA Online Screen

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www.nationaleatingdisorders.org/screening-tool

Who Should Be Screened? ● All adolescents & adults as part of new patient

visits and annual physical paperwork, and in particular:

❏Adolescents (12-25 years)

❏Athletes

❏Patients with a family history of eating disorders

❏Patients with trauma history

❏Patients seeking help for weight loss or history of chronic dieting

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Who Should Be Screened?Patients with certain medical conditions:

❏ Diabetes mellitus, Type 1 and 2❏ Polycystic ovarian syndrome❏ Irritable bowel syndrome, Chronic constipation❏ Hypothalamic amenorrhea❏ POTS (Postural orthostatic tachycardia syndrome)❏ Autoimmune conditions

Patients with psychiatric comorbidities:

❏ Mood disorders ❏ Anxiety disorders❏ Substance use disorders

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Common Symptoms and Medical Complications

• Fatigue and malaise • Temperature dysregulation

– Cold/heat intolerance• Cardiovascular

– Dizziness, fainting, slow or fast heart rate, swelling• Endocrine

– Amenorrhea or irregular periods, infertility, osteoporosis, stress fractures

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Common Symptoms and Medical Complications

• Gastrointestinal complaints – Constipation, heartburn, IBS, bloating

• Hematologic– Anemia, low white blood count

• Metabolic or electrolyte abnormalities – Low potassium, low sodium, urine ketones

• Vitamin deficiencies • Cognitive symptoms

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Weight and ED Presentation• Weight fluctuations

• Weight suppression

• Lack of weight gain or height growth in adolescents

• ED symptoms and behaviors can occur in individuals of any body size

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Medical Assessment: Vitals• Blood pressure, Heart rate, Temperature,

Respirations, Oxygen saturation• Orthostatic vital signs

– Blood pressure and heart rate lying, sitting, and standing

• Height and weight– Blind weight in gown

– Avoid documenting weight on after-visit summary printout or patient portal

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Medical Assessment: Exam

❖ Skin/hair

❖Head, Eye, Ears, Nose, Throat

❖Neck

❖Cardiovascular❖Respiratory❖Abdominal❖Musculoskeletal

❖Neurologic

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● Thorough physical examination in a gown

Medical Assessment: Laboratory testingBlood testing Urine testingBlood counts Urinalysis

Kidney tests/electrolytes Urine pregnancy test

Liver function tests Urine drug toxicology

Pancreatic enzymes

Thyroid function tests

Hormone levels

Vitamin/mineral levels

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Medical Assessment: Testing• Most patients:

– EKG

• Some patients: – Echocardiogram

– X-ray imaging

– Bone density test

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Approaching a Patient – Do’s • Inform the patient of their symptoms and why

they concern you

• Provide information on harmful effects of eating disorders on physical health

• Inform them of available treatment options and that you are supportive

• Remind them of your confidentiality as their healthcare provider

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Approaching a Patient – Don’ts

• DO NOT approach the topic in an open area with others around

• DO NOT use language that blames or shames (instead, use non-judgmental language)

• DO NOT give simple solutions “you just need to eat”

• DO NOT make any appearance-based comments

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Treatment Options• Levels of care

• Inpatient (hospital-based; medically acute)

• Residential (less medically acute)

• Partial hospitalization/day treatment

• Intensive outpatient (3-7x/week)

• Outpatient (~1x/week)

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APA Level of Care Guidelines for Management of Eating disorders: Guidelines on NEDA website, Yager et al APA Practice Guidelines

Outpatient treatment: Team Approach

● Referral to outpatient eating disorders specialists

● Team members ○ Psychotherapist○ Registered dietitian○ Primary care provider ○ Psychiatrist

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Treatment Options: Team Approach

● Nutritional counseling: ○ Meal plans, use of food exchanges○ Intuitive eating○ Moderation/discontinuation of exercise

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Treatment Options: Team Approach● Psychotherapy:

○ Cognitive Behavioral Therapy (CBT): Identifying, challenging, and changing maladaptive thoughts that often influence emotions and behavior; identifying and modifying behavioral patterns

○ Family-based therapy: Parents/guardians deliver treatment○ Dialectical Behavior Therapy (DBT), Acceptance and

Commitment Therapy (ACT), Interpersonal Psychotherapy (IPT)○ Group therapy

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Treatment Options: Team Approach

● Medical provider: ○ Evaluation and management of medical

complications● Pharmacotherapy:

○ Limited pharmacologic agents for EDs○ Treatment for comorbid psychiatric

conditions

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Providing Referrals

• Work with local centers and providers when possible– www.findedhelp.com

• Consistent communication is key!

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9 Truths About Eating DisordersTruth 1: Many people with eating disorders look healthy, yet may be extremely ill.

Truth 2: Families are not to blame, and can be the patients’ and providers’ best allies in treatment.

Truth 3: An eating disorder diagnosis is a health crisis that disrupts personal and family functioning.

Truth 4: Eating disorders are not choices, but serious biologically influenced illnesses.

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9 Truths About Eating DisordersTruth 5: Eating disorders affect people of all genders, ages, races, ethnicities, body shapes and weights, sexual orientations, and socioeconomic statuses.

Truth 6: Eating disorders carry an increased risk for suicide and medical complications.

Truth 7: Genes and environment play important roles in the development of eating disorders.

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9 Truths About Eating DisordersTruth 8: Genes alone do not predict who will develop eating disorders.

Truth 9: Full recovery for an eating disorder is possible. Early detection and intervention are important.

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References• American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders 5th ed. Washington, DC:

American Psychiatric Association; 2013• Balantekin KN, Birch LL, Savage JS. Eating in the absence of hunger during childhood predicts self-reported

binge eating in adolescence. Eat Behav. 2017;24:7–10. doi:10.1016/j.eatbeh.2016.11.003• Becker CB, Middlemass K, Taylor B, Johnson C, Gomez F. Food insecurity and eating disorder pathology. Int J

Eat Disord. 2017;50(9):1031-1040. doi: 10.1002/eat.22735• Bulik CM, Sullivan PF, Kendler KS. Genetic and environmental contributions to obesity and binge eating. Int J Eat

Disord. 2003;33(3):293-298. doi:10.1002/eat.10140• Eating disorders: A Guide to Medical Care. AED Report 2016. 3rd edition.• Fairburn CG, Doll HA, Welch SL, Hay PJ, Davies BA, O’Connor ME. Risk factors for binge eating disorder: a

community-based, case-control study. Arch Gen Psych. 1998;55(5):425-432. doi: 10.1001/archpsyc.55.5.425• Garber, AK. Moving beyond “skinniness”: Presentation weight is not sufficient to assess malnutrition in patients

with restrictive eating disorders across a range of body weights. J Adolesc Health. 2018;63(6):669-670. doi: 10.1016/j.jadohealth.2018.09.010.

• Graham et al. J Am Coll Health. A screening tool for detecting eating disorder risk and diagnostic symptoms among college-age women. 2019 May-Jun;67(4):357-366. doi: 10.1080/07448481.2018.1483936. Epub 2018 Oct 9.

• Grilo CM, Masheb RM. Childhood psychological, physical, and sexual maltreatment in outpatients with binge eating disorder: frequency and associations with gender, obesity, and eating-related psychopathology. Obes Res. 2001;9(5):320-325. doi: 10.1038/oby.2001.40

• Harrington et al. Initial Evaluation and Treatment of Anorexia nervosa and Bulimia nervosa. Am Fam Physician. 2015. Jan 1;91(1):46-52.

• Herman BK, Deal LS, DiBenedetti DB, Nelson L, Fehnel SE, Brown TM. Development of the 7-Item Binge-Eating Disorder Screener (BEDS-7). Prim Care Companion CNS Disord. 2016;18(2) doi: 10.4088/PCC.15m01896

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References• Hilbert A, Pike KM, Goldschmidt AB, et al. Risk factors across the eating disorders. Psychiatry Res. 2014;220(1-

2):500-506. doi: 10.1016/j.psychres.2014.05.054.• Kutz et al. J Gen Intern Med. Eating Disorder Screening: a Systematic Review and Meta-analysis of Diagnostic

Test Characteristics of the SCOFF. 2019 Nov 8. doi: 10.1007/s11606-019-05478-6.• Maguen S, Hebenstreit C, Li Y, et al. Screen for Disordered Eating: improving the accuracy of eating disorder

screening in primary care. Gen Hosp Psychiatry. 2018;50:20-25. doi: 10.1016/j.genhosppsych.2017.09.004• Mehler, Philip and Arnold Anderson. Eating disorders: A Guide to Medical Care and Complications. Johns Hopkins

Univ Press, 2017.• Mitchell KS, Neale MC, Bulik C, et al. Binge eating disorder: a symptom-level investigation of genetic and

environmental influences on liability [published correction appears in Psychol Med. 2010 Nov;40(11):1907-8]. Psychol Med. 2010;40(11):1899–1906. doi:10.1017/S0033291710000139

• Morgan JF, Reid F, Lacey JH. The SCOFF questionnaire: a new screening tool for eating disorders. West J Med. 2000;172(3):164–165. doi:10.1136/ewjm.172.3.16

• Puhl R, Suh Y. Health consequences of weight stigma: implications for obesity prevention and treatment. Curr Obes Rep. 2015;4(2):182-190. doi: 10.1007/s13679-015-0153-z

• Schaumberg K, Welch E, Breithaupt MA, et al. The science behind the Academy for Eating Disorders’ Nine Truths About Eating Disorders. Eur Eat Disord Rev. 2017;25(6):432-450. doi: 10.1002/erv.2553

• Vartanian LR, Porter AM. Weight stigma and eating behavior: a review of the literature. Appetite. 2016;102:3-14. doi: 10.1016/j.appet.2016.01.034

• Yager et al. Practice Guideline for the Treatment of Patients with Eating disorders. Third Edition. 2010.

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Questions?

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eating disorders 101: signs, symptoms, screening, and referral€¦ · anorexia nervosa (an)...

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